Medical Improv For Building IPU’s (Integrated Patient Units)

IPUs (integrated practice units), a concept advanced by Porter, M.E. and Lee, T.H. (see article below) promotes organizing holistic care for groups of patients with similar needs. It’s been noted that cohesive teams who follow patients over time are able to do a better job of delivering quality patient care. In order to optimally perform, trust, communication, coordination, and collaboration must be infused at every level of these healthcare organizations. Medical Improv is a fun, creative way to actually PRACTICE building these necessary teams.

Teamwork can help healthcare organizations compete more effectively in today’s marketplace.

How can healthcare providers differentiate themselves from their competitors? This question is becoming increasingly important in the evolving healthcare marketplace, with its growing emphasis on provider competition for market share. If providers deliver the exact same services as their competitors in the same way, they inevitably will end up competing on price, and margins will fall. On the other hand, providers that effectively differentiate themselves from their competitors gain an opportunity to retain or increase their market penetration, and share in the value that they create.

Regardless of how much of a provider’s revenue comes from fee-for-service or from some form of value-based payments, one of the best competitive differentiators from a strategic standpoint is demonstrating exemplary teamwork. Provider organizations with great teams are more effective in improving quality and reducing costs than are organizations whose clinicians are disorganized and do not work well together. With strong teamwork, morale is higher, which typically translates into lower turnover. And high-performing teams give provider organizations an excellent chance for success in new payment models, such as bundled payments.

Providers should recognize that effective teamwork doesn’t happen by accident. Organizations that work to cultivate teamwork have a competitive advantage that can translate into business success.

Why Teamwork Matters Now

Teamwork is a crucial topic for healthcare organizations today that demands the attention of senior executives. The tremendous medical progress that has occurred over the past few decades has enabled providers to do much more for patients than they could in the past, but it has also made treatment more complex. Delivering comprehensive care requires multiple individual clinicians, each having an increasingly narrow focus. All too often, these clinicians do not even know each other. They could walk right by each other in the hallways and not know that they were collaborating in the care of the same patient.

The resulting perception of disorder and lack of coordination contributes to patients’ concerns about whether their clinicians are truly working together on their behalf. And the actual disconnects in the care process exacerbate these concerns by leading to safety issues, reduced quality, and inefficiency.

The lack of coordination and teamwork also is dispiriting for physicians, nurses, and other clinicians, who are aware of it and absorb complaints about it from patients and their families. These clinicians often feel anonymous in their own institutions and unsupported by any meaningful degree of respect from close colleagues because such relationships are so rare. From an operational perspective, clinicians who lack a sense of loyalty to their colleagues or their institutions have little compunction about leaving, which creates additional expense and further problems with morale and a poor patient experience. Unfortunately, this picture all too accurately represents the status quo in many organizations and within many subsets of providers.

Even if change were not sweeping the healthcare marketplace, creating a spirit of teamwork would be an important undertaking. But in today’s environment—with every provider organization seeking to grow, with employers and payers developing bundled payment arrangements, and with new entrants seeking to siphon away some of the most profitable services—the goal of delivering superbly coordinated care to retain patients has become a strategic imperative.

Teamwork Works

Better teamwork promotes greater quality, a better patient experience, and a prouder work force, all of which contribute to better financial performance. These relationships are demonstrated in three analyses performed in early 2016 to assess the value of teamwork.

The findings of an analysis of the relationship of teamwork and quality are summarized in the below exhibit. The concept of teamwork is assessed through employee-reported data on how well different units within the provider organization coordinate their work. Two different types of publicly reported data are used to assess quality. The 12 top bars reflect the correlation between the response of participants in a patient experience survey regarding their perception of teamwork within an organization (represented by the statement “Units coordinate with each other”) and their responses regarding other aspects of their experience with that same organization. The bars projecting to the right signify a positive statistical correlation—and the further they project to the right, the greater the correlation coefficient. The fact that all ratings extend to the right means that a perception of teamwork correlates with an overall better perception of the patient experience. The bottom bar, which goes to the left, indicates that a strong sense of teamwork among the employees correlates with a lower rate of central-line-associated blood stream infections (CLABSIs), an important patient safety indicator.

The exhibit below shows analyses of teamwork as it relates to employee engagement data. The correlations indicate that organizations with better teamwork have a workforce that is more engaged in other ways. The rows are three variables that reflect the sense of teamwork within the organization. The columns are other key employee engagement variables. The numbers in the cells are the correlation coefficients, all of which are positive and highly statistically significant. The bottom line is that teamwork tracks with employees’ sense of pride and desire to remain with the organization.

The third exhibit shows the relationship between hospital financial performance and patient experience (a key output from teamwork). For this figure, hospitals were divided into quintiles based on their patient experience data (a summary of their performance on HCAHPS survey measures). The hospitals’ publicly reported operating margins tended to track with patient experience performance.

These figures do not reflect experiments in which hospitals were randomly assigned to “good” versus “bad” teamwork conditions, so these analyses do not prove cause-and-effect relationships. For example, there are surely many other factors that influence financial margin. But the train of logic that good teamwork contributes to better care, and that better care contributes to better financial health, seems unassailable.

Real Teams Versus Pick-up Teams

Building teamwork that confers a strategic advantage requires more than senior management exhortations that everyone get along and work together. Teams have to know that they are a team. They have to know why they exist. They have to understand their performance and want to improve.

As organizations grasp the effect of competition on value, their understanding of the nature and importance of teams is deepening. Not long ago, physicians tended to think of teams as groups of personnel who would do their bidding and enhance their ability to perform billable services. But with today’s more patient-centric focus, with an explicitly greater emphasis on meeting patients’ needs than on simply generating relative value units, there now is a greater need for healthcare teams to be multidisciplinary groups that can address all of a patient’s care requirements in a way that is simply not feasible for unfocused pickup teams. For example, with pickup teams, clinicians who are supposed to be working together on behalf of a patient may not actually know each other, are less likely to share knowledge in informal interactions, and exert less peer pressure on each other to maintain high standards of teamwork and individual excellence.

Yet assembling multidisciplinary groups with complementary roles and responsibilities also is not enough. The goal of having clinicians practice “at the top of their license” is important, but there is an even more critical objective: fostering the identity of the team as a single unit with the goal of meeting patients’ needs. That means team members should be prepared and motivated to help each other and be adaptable in meeting patients’ needs, whatever they may be.

This insight that teams are much more than “focused factories” producing services—e.g., hernia repairs or cataract removal—is inherent in the concept of integrated practice units (IPUs) advanced by Michael Porter and this author.a IPUs are organized to provide holistic care for groups of patients with similar shared needs, usually defined by conditions (e.g., breast cancer or diabetes). The premise is that those conditions are best treated by teams that can follow patients over time, which enables them to do a better job of educating patients than a single physician can during sporadic office visits.

IPUs also are prepared to meet the most common other needs that occur in patient segments. For example, patients with diabetes require treatment of diabetes, of course, but many also need care for kidney, cardiac, and neurological complications. Having the personnel that can meet these common care requirements integrated within the IPU ensures patients receive care that is better, smoother, and more efficient.

Key Steps for Building IPUs

Although no team can meet all the needs of all patients who have a common medical condition, being able to meet most of the needs is a major competitive differentiator for a healthcare provider. For this reason, senior executives take the following steps to create IPUs that embody the very essence of teamwork.

Decide where the organization will compete. No organization can differentiate itself on everything. If organizations cannot make choices, the risk for mediocrity on everything is high. Provider organizations should identify the conditions for which they will marshal their resources to improve value, and then commit to doing what is necessary to meet patients’ needs as efficiently as possible.

Identify who should be on the team. The objective here is to identify those disciplines that, by working closely together, can deliver high-value care. Nonphysician clinical personnel such as physical therapists, pharmacists, and nurse educators obviously are critically important, but so are administrative personnel to assist patients with scheduling and financial issues.

Strive to co-locate the team. Teams need to know each other, not only to exchange information but also to build trust and real relationships. Team members should want to work hard to earn the respect of their colleagues, and should hate the idea of ever disappointing them.

Measure the outcomes that matter to the patients the IPU was created to serve. These should not be process measures that team members feel are most likely to be under their control. The measures should be actual targeted outcomes, including a high-quality patient experience. These are the performance measures that will draw market share to the team and the organization.

Establish true leadership and accountability. Someone should be in charge of the IPU, and ideally, it should be its own business unit—a profit-and-loss center. Only when teams are truly responsible for their financial performance do they work relentlessly to improve efficiency. Note that once that accountability is created, the IPUs will be intensely interested in understanding their true costs, so they can try to manage them.

Negotiate contracts that reward efficiency. Bundled payments are the most obvious example. Payment should align with the move from volume to value in health care.

Push transparency of performance metrics. These metrics should ideally be made available publicly via the internet, but if not, they should be disseminated internally through sharing of data among providers, including those in other organizations. The major impact of transparency is to drive improvement by providers. Nothing works as well.

Teamwork is not just a human resources issue. It is a necessary strategic focus for the entire senior leadership team. Just as senior executives give major attention to amassing financial capital, so too must they amass social capital, which is created through relationships and the way personnel work with one another to achieve shared goals. Given the complexity of health care today, social capital is at least as important as financial capital. After all, organizations often can borrow money, but they cannot go elsewhere to arrange infusions of trust, coordination, and collaboration.

Progress in medicine is wonderful, but it also can be disruptive. Coordination is the antidote for that disruption, and great teams reflect coordination in its purest and most powerful form. Through IPUs and other innovative models, excellent teams are emerging wherever providers are seriously tackling the challenge of high-value health care. These models provide vehicles through which healthcare providers can improve their care and achieve business success.